Nokea
A client is having blood tests and has an elevated lymphocyte level. Based on knowledge of cellular components, what does the nurse know about these cells?
- A. Contain histamine and provide protection during allergic reactions
- B. Are involved in phagocytosis
- C. Provide protection and immunity against foreign substances
- D. Carry hemoglobin and oxygen to body tissues
Correct Answer: C
Rationale: Lymphocytes are a type of white blood cells that play a crucial role in supporting the body's immune system. They are responsible for producing substances that protect the body against infections and foreign substances that could potentially harm the client. Lymphocytes consist of two main types: T cells, which are produced in the thymus, and B cells, which are produced in the lymphatic tissue. Choice A is incorrect because histamine is mainly associated with basophils and mast cells, not lymphocytes. Choice B is incorrect as phagocytosis is a function of other white blood cells such as neutrophils and macrophages. Choice D is also incorrect as carrying hemoglobin and oxygen is a function of red blood cells, not lymphocytes.
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Mrs. F has been diagnosed with hyperparathyroidism. Which of the following complications is Mrs. F at highest risk of developing?
- A. Hyponatremia
- B. Hypocalcemia
- C. Hypermagnesemia
- D. Hypercalcemia
Correct Answer: D
Rationale: The parathyroid glands regulate calcium, vitamin D, and phosphorus in the body. Hyperparathyroidism leads to excessive production of parathyroid hormone, causing the release of calcium from bones into the bloodstream, resulting in elevated blood calcium levels, known as hypercalcemia. This puts individuals at risk of developing complications such as kidney stones, bone pain, osteoporosis, and neuropsychiatric symptoms. The other options, hyponatremia, hypocalcemia, and hypermagnesemia, are not directly associated with hyperparathyroidism. Hyponatremia is low sodium levels in the blood, hypocalcemia is low calcium levels, and hypermagnesemia is high magnesium levels, which are not typically seen in hyperparathyroidism.
A nurse is caring for a 3-day old infant who needs an exchange transfusion. Which of the following statements is appropriate for teaching the child's parents about this procedure?
- A. The registered nurse will be performing the procedure
- B. The procedure takes approximately 1 ? hours.
- C. The nurse will draw out 250cc of blood and then immediately replace it with 250cc
- D. The infant will continue to receive phototherapy during the procedure.
Correct Answer: B
Rationale: : An exchange transfusion is a method of controlling high bilirubin levels in infants when traditional phototherapy is unsuccessful. During an exchange transfusion, the physician removes 5-10 cc of blood and then replaces it with donor blood. The parents of this infant should know that the procedure is always performed by a physician and will take approximately 1 ½ hours to complete.
A client has a prescription for ketoconazole. Which instruction should the nurse teach the client to follow while taking this medication?
- A. Avoid exposure to sunlight.
- B. Limit alcohol to 2 ounces per day.
- C. Take the medication with an antacid.
- D. Take the medication on an empty stomach.
Correct Answer: A
Rationale: The client should be taught that ketoconazole is an antifungal medication. The client should avoid exposure to sunlight because the medication increases photosensitivity. The client should avoid the concurrent use of alcohol because the medication is hepatotoxic. Antacids should be avoided for 2 hours after it is taken because gastric acid is needed to activate the medication. This medication should be taken with food or milk.
While caring for a client who has just come from surgery and is in the recovery room with an endotracheal tube in place, the nurse deflates the cuff on the tube and removes it. The client sits up in bed, grasps his throat, and begins to make wheezing sounds. Which of the following conditions is the most likely cause of this situation?
- A. The client is choking on part of the tube
- B. The client has anxiety
- C. The client is having a laryngospasm
- D. The client is having a normal response from anesthesia
Correct Answer: D
Rationale: After surgery, some clients may experience a laryngospasm during emergence from anesthesia. A laryngospasm can lead to the closure of the laryngeal opening due to spasm of the vocal cords. In this scenario, the client's symptoms of wheezing and throat grasping are indicative of a laryngospasm rather than choking on the tube, anxiety, or a normal response from anesthesia. The nurse should act promptly to open the airway to aid breathing and consider administering muscle relaxants as necessary.
The nurse should tell the client to avoid which item while taking phenelzine sulfate?
- A. Blueberries
- B. Vasodilators
- C. Aged cheeses
- D. Digitalis preparations
Correct Answer: C
Rationale: Phenelzine sulfate is in the monoamine oxidase inhibitor (MAOI) class of antidepressant medications. An individual taking an MAOI must avoid aged cheeses, alcoholic beverages, avocados, bananas, and caffeine drinks. There are also other food items to avoid, including chocolate, meat tenderizers, pickled herring, raisins, sour cream, yogurt, and soy sauce. Medications that should be avoided include amphetamines, antiasthmatics, and certain antidepressants. The client should also avoid vasoconstrictors because their concurrent use can cause hypertensive crisis.